Management of HPV 18‑Positive Low‑Grade Cervical Dysplasia

Risk Assessment and Need for Immediate Colposcopy

The CDC STI Treatment Guidelines state that HPV 18 markedly increases the risk of cervical adenocarcinoma, so colposcopy is recommended for all HPV 18‑positive women even when cytology is normal. 1
Because HPV 18 is strongly associated with adenocarcinoma, the CDC recommends endocervical sampling at the time of colposcopy. 2

If not already performed, endocervical sampling should be obtained during colposcopy in HPV 18‑positive patients because of the virus’s adenocarcinoma risk. 1
Directed biopsies of any visible lesions must be taken during colposcopy for accurate histologic grading. 4

When colposcopy is satisfactory (transformation zone fully visualized) and CIN 1 is confirmed, repeat HPV testing at 12 months (or Pap testing at 6 and 12 months) is the preferred follow‑up. 4
If the repeat cytology shows ≥ ASC‑US or the high‑risk HPV test remains positive, the patient should be referred back to colposcopy. 4
After two consecutive negative cytology results or a negative HPV test, the patient returns to routine annual cervical cancer screening. 4

Ablative (cryotherapy, laser ablation) or excisional (LEEP) modalities are acceptable for CIN 1 when treatment is chosen. 5
Endocervical sampling is required before performing any ablative procedure on CIN 1 lesions. 5

The ASCCP risk‑based guidelines recommend that HPV testing or cotesting (HPV + Pap) be used for follow‑up after an abnormal result in HPV 18‑positive women, rather than cytology alone. 1
At the 1‑year follow‑up visit, an HPV test with or without a concurrent Pap test should be performed. A persistent positive HPV result or abnormal cytology mandates return to colposcopy. 7
If the 1‑year HPV test is negative, surveillance can be continued with HPV testing or cotesting every 3 years (or annual cytology if that is the chosen modality). 1
Because HPV 18 confers a higher oncogenic risk, a lower threshold for treatment is advised if CIN 1 persists beyond 12–24 months. 1
Deferring the first reassessment beyond 12 months is not recommended for HPV 18‑positive patients. 1

If the transformation zone is not fully visualized, a diagnostic excisional procedure (LEEP, laser conization, or cold‑knife conization) is the preferred management; ablative methods are not acceptable for CIN 1 in this setting. 4

Immediate excisional procedures without histologic confirmation of CIN 2 or CIN 3 are not acceptable for initial management of HPV 18‑positive CIN 1. 8
Performing ablative treatment without prior endocervical sampling is discouraged. 4

Women with a history of HPV 18‑positive low‑grade dysplasia require extended surveillance beyond the initial resolution phase. 1
Long‑term follow‑up should consist of HPV testing or cotesting every 3 years (or annual cytology if that is the chosen strategy). 1